Identifying and treating children’s pain

There is a widespread view that childhood pain is under-recognised and under-managed, writes Leanne Philpott

Pharmacists play a valuable role in helping parents assess the severity of their child’s pain, select an analgesic and administer the appropriate dose.

Our view of pain has changed markedly over the years; we now recognise that children experience pain just as much as adults and failure to treat or inadequate treatment can have long-term consequences.

According to the Royal Children’s Hospital in Melbourne, optimal pain management is the right of all patients and the responsibility of all health professionals. However, assessing pain in children differs from assessment in adults due to the often-reduced ability of younger patients to understand and describe their pain.

“As pharmacists we tend to assume parents know how to manage pain and assess pain but, particularly when a child is in pain, this is often very difficult,” says Christine Onishko, senior pharmacist— Pain Management at Adelaide Women’s and Children’s Hospital.

“We need to give the parent information to assist them in assessing whether their child is in pain and if they need medication.”

While the Faces Pain Scale (revised) is a useful tool for healthcare practitioners, Onishko says parents can take a more practical approach to assessing their child’s pain.

“It might be as simple as asking: can the child sleep or is the pain waking them at night? Can the child eat even though they have a sore throat? Is their headache stopping them from sleeping or functioning?

“Parents don’t have to use a pain measurement scale; in the community it’s about looking at what impact the pain is having and then it’s easy to work out if treatment is required.

“Behavioural cues can be a good telltale sign of a child’s level of pain and this is something that the parents have the greatest chance of measuring, after all, they know their child best.

“Often it’s the noisy child, that might be crying or grizzling, that gets the treatment but the other way children cope with pain is to become stiff as a board, motionless, quiet and withdrawn,” advises Onishko.

Karin Plummer, PhD researcher, Murdoch Children’s Research Institute, says when children self-report pain, it’s important to be aware of the context surrounding the pain.

“Are they sacred, do they not want to go to school? You need to look at their behaviour and whether it’s consistent with the pain they’re reporting.

“I also like to look at ‘comfort goals’. The child might say their pain is a 10 out of 10, so I ask them what number would be comfortable for them. They might say a 2 or some might even say an 8/10 would be comfortable for them. It’s interesting what they come out with. This approach can be effective with children whose pain scores don’t make sense.

“Kids are also very good at hiding pain, particularly if they don’t trust you. I’ve seen children who are clearly in the most severe pain deny it. They may be scared of what pain means or, if they’ve never had a really painful situation before, they might not understand their pain.”

Treating paediatric pain

“There can be quite a limited arsenal available to treat pain, particularly with the new legislation around codeine,” says Plummer.

“It’s about making the best of what you have, using multimodal agents and not just relying on the pharmacological approaches.”

Plummer notes, “Everyone presumes the parent knows when their child is in pain and while it’s true, a parent does know their child best, often they can’t gage how severe the pain is.

“An important role for pharmacy is to help parents assess the severity of their child’s pain. If the pain is mild, paracetamol might be appropriate or if it’s moderate pain they might use multimodal analgesia. In the case of severe pain, it might warrant referral to a doctor or the hospital.

“If parents are sleep deprived, because they’ve been up all night with a child in pain, trying to calculate the appropriate dose can be perplexing. When I worked in the Emergency Department I found a lot of parents would give their child paracetamol, but they weren’t giving enough. Parents always seem to choose the lowest end of the dosing scale.”

Onishko says, “Generally speaking analgesic dosing should be guided by the child’s weight. If it’s an obese child, the parent might want to discuss the dosing with the pharmacist. Dosing may need to be guided by the child’s ‘ideal’ body weight rather than their actual body weight, but that’s only for really obese children.

“In general parents should use the recommended dose per milligram for their child’s age and weight.”

She notes, “There are misconceptions amongst parents that you shouldn’t treat pain unless you really have to, but evidence has shown that children and adults recover quicker if their pain is managed properly.

“Rather than using the lowest dose possible, parents should be advised to use the correct dose; otherwise they might as well not give the analgesic at all.

“Parents are often worried that medicines are addictive but 99.9% of the time that’s not the case. There’s also the misleading notion that pain makes you stronger and that’s simply not true. If the child is in pain they deserve to have their pain treated.

“As an adult you can choose whether you want to put up with your pain; kids have no choice. The parents have to make the decisions and be the advocates for the child and if pain exists, it should be treated.

“Even when dealing with acute pain, if it’s present all the time, then the child needs regular doses of analgesics. Parents should not wait until the pain gets really bad to give the child analgesic medicine.

“If the pain is infrequent, an analgesic can be administered every now and then when the pain is present.”

Over-the-counter paediatric analgesia comes down to a choice between ibuprofen and paracetamol. “We recommend using one analgesic, using it regularly and using it well,” says Onishko.

“Ibuprofen and paracetamol work on different pathways of pain transmission, with ibuprofen having anti-inflammatory properties. We use ibuprofen after children have had surgery or where inflammation may be present.”

While alternating doses of ibuprofen and paracetamol may be carried out in a clinical setting, Onishko says parents who do this may run the risk of medication errors, particularly as paracetamol is given every four hours whereas ibuprofen is given every eight hours and there may be differences in the doses.

“The most important way to avoid dosing errors is to make sure parents read the label properly. There are different strengths of analgesics so it’s no use for parents to remember what they gave their child last time, particularly if they’re using a different product.

“Pharmacists can remind parents to always read the label and choose the dose that’s applicable to that particular analgesic,” says Onishko.

She adds, “It’s also important for parents to know and to be reminded that there are multiple routes of administration that can be used for analgesics. If a child is not able to swallow they might think about suppositories, for example.”

Which analgesic?

Analgesics for infants and children come in several forms; pharmacists and their staff can advise parents on the most appropriate form for their child’s pain.

  • Drops. A concentrated form of the analgesic. Commonly recommended for infants and young children due to ease of administration.
  • Suspensions. The active ingredient is ‘suspended’ in the liquid, making it thicker and assisting with administration.  It requires shaking before use. Similar to drops, suspensions concentrate the formula, which can mean lower-volume dosing.
  • Elixirs and syrups are thinner liquid products with the active ingredient dissolved and an agent added to mask its bitter taste.
  • Chewable tablets are suitable for children aged three and older (check the package). They do not require water so can be useful when out and about or travelling.  
  • Effervescent tablets are available for children seven years and older.
  • Suppositories may be helpful if a child can’t tolerate oral analgesics. They are available for children aged six months plus.

Non-pharmacological strategies

Plummer says, “We have lots of easy, simple non-pharmacological strategies that work really well for pain. Used in conjunction with analgesics, these approaches can really help children with their pain.

“When dealing with general pain, we can use comfort measures, hot or cold compresses, distraction, relaxation and mindfulness techniques.

“People underestimate how important non-pharmacological strategies are for reducing the distress associated with pain. They work on the pain gate by reducing the amount of pain input coming in. They’re more than just ‘a nice idea’; they actually work on our awareness of pain and reduce the amount of pain perceived.

“Many of these techniques parents adopt naturally, but it’s important to give them the recognition that the strategies they’re using are helping.”

Onishko says, “People expect pharmacists to talk about the medicines that can be used to address a child’s pain; discussing the non-pharmacological approaches to pain is very powerful.

“Things like distraction and hypnotherapy can be really useful. Distraction is as easy as reading the child a story or singing songs with them to take their mind off the pain, so you don’t have to use as much pharmacological treatment.

“Even something as simple as playing a game on the iPad is a distraction technique that can reduce the amount of pharmacological intervention needed.

“We know that when kids focus on their pain they feel it more, so it increases the intensity of it; if you can distract them it can be beneficial to their experience of pain.”

Plummer adds, “If we don’t work to give children the best possible experience of pain we’re setting up fear and anxiety. By re-moulding a child’s memories of pain, they’re going to cope a lot easier in the future.”

Pharmacists can play a key role by:

  • Helping parents recognise the severity of their child’s pain
  • Guiding parents on appropriate analgesic dosing
  • Providing education on the non-pharmacological approaches to pain.

“I think parents are a really important area to target in children’s pain, as ultimately they are the ones making the decisions,” says Plummer.








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